Gastrointestinal: Diffuse pancreatic cysts treated by duodenum-preserving and spleen-preserving total pancreatectomy
Question:
An 18-year-old man presented to hospital with a three-year history of recurrent epigastric pain and steatorrhea. Examination showed facies dolorosa, epigastric tenderness, and an exceptionally low BMI of 15.21 kg/m2. Lab indicated TP at 46.2 g/L, Alb at 29.5 g/L, FBG at 20.8 mmol/L, NGSP-HbA1c at 16.9%, CEA at 7.11 ng/mL, and CA-199 at 83.26 U/mL. CT and MRI revealed multiple pancreatic cysts, and lesion involves the whole pancreas, with no evidence of peripancreatic seepage, enlargement of lymph nodes, or solid neoplasms (Figure 1a,b).
- Pancreatic abscess; expectant treatment.
- Pancreatic abscess; medical therapy.
- Chronic pancreatitis; total pancreatectomy.
- Pancreatic cysts; function-preserving total pancreatectomy.
Answer: (D). The patient was diagnosed with diffuse pancreatic cysts, and the next best step in treatment is duodenum-preserving and spleen-preserving total pancreatectomy.
The patient's typical imaging features, in conjunction with other findings, confirmed the final diagnosis of multiple pancreatic cysts. Furthermore, the tumor markers were only mildly elevated. Both CT and MRI showed no signs of malignant tumor; therefore, benign multiple whole pancreatic cysts were diagnosed. To preserve organ function, reduce surgical trauma, enhance recovery, and minimize complications, a laparoscopic duodenum-preserving and spleen-preserving total pancreatectomy (TP) was performed, multiple total pancreatic cysts were observed during the operation (Fig. 2a). The keypoint is ensuring the integrity of posterior superior pancreatoduodenal artery and posterior inferior pancreatoduodenal arterial (Fig. 2b, postoperative structure). Surgery was successful, and whole pancreas was resected (Fig. 2c). Histopathology identified non-neoplastic cystic lesion with atrophic changes in the surrounding pancreatic tissue (Fig. 2d). Postoperatively, the patient was managed with daily insulin and pancreatic enzymes. After 2 years, his HbA1c and BMI recovered 10.5% and 18.25 kg/m2, abdominal pain was resolved, and other biochemical indicators were normalized.
Congenital simple pancreatic cysts are exceedingly rare, and they are generally non-malignant.1 While asymptomatic cysts typically do not require monitoring or surgical intervention, symptomatic pancreatic cysts may need surgical removal.2 Laparoscopic duodenum-preserving and spleen-preserving TP is a secure, viable, function-preserving, and innovative surgical technique.
